Patient Registration Process
It is important the information you provide be accurate since we will rely on this data to provide your medical care now and in the future.
Whenever there is a change of address, telephone number, or insurance coverage, please tell us.
Failure to provide us with accurate information (phone numbers, addresses, alternate contacts) may prevent or delay the physicians or clinical staff from contacting you regarding the health of your child.
Failure to inform us of changes in insurance coverage could result in you having to pay the entire bill.
Use the links below to fill out Family/Patient Registration Forms prior to your first office visit.
All Patients (including former patients of Dr. Donald's) please complete each step.
Our office needs one form per family with the exception of the Health History form which we require one per patient.
Call our offices if you have questions.
Adobe Acrobat Print and Fill-in Form Documents
Step 1
Click here to goto our Family Registration Form
(One form per family.)
Step 2
Click here to goto our Authorization to Treat and HIPAA Acknowledgement Form
(One form per family. (PRINT IN LANDSCAPE FORMAT)
Step 3
Click here to goto our Assignment of Benefits Form
(One form per family.)
Step 4
Click here to goto our Authorization to Release PHI School/Dayschool/Camp Form
(One form per family.)
Step 5
Click here to goto our Health History Form
(Please fill out one form for each child.)
Step 6
Click here to goto our HIPAA Privacy Policy
(This form is for your records.)
